-
Chief Complaint
The reason the ambulance was called
-
Differential Field Diagnosis
The list of possible causes for your patient's symptoms
-
Open-Ended Questions
Questions that allow your patient to answer in detail
-
Closed-Ended Questions
Questions that elicit a one or two word response
-
Active Listening
The process of responding to your patient's statements with words or gestures that show your understanding
-
Active Listening Skills
- Facilitation- saying "mm hmm" or "go on" as the patient is talking to you
- Reflection- repeat the patients words in a question
- Clarification- asking questions about the patients statements to get more information
- Empathy- saying things like "that must be very hard for you"
- Confrontation- letting the patient know that you think there is more going on
- Interpretation- "are you afraid you are having a heart attack but don't want to admit it?"
-
Comprehensive Patient History
- Preliminary Data
- Chief Complaint
- Present Injury/Illness
- Past History
- Current Health Status
- Review of Systems
-
Preliminary Data
- -Date and Time of exam
- -Age
- -Sex
- -Race
- -Birthplace
- -Occupation
-
Chief Complaint
Determine the CC and Primary Problem
-
Primary Problem
The underlying cause of the patients symptoms
-
Present Illness
OPQRST-ASPN
nset of problem - Provocative/Palliative factors
- Quality
- Region/Radiation
- Severity
- Time
- Associated Symptoms
- Pertinent Negatives
-
Tenderness
Pain that is elicited through palpation
-
Referred Pain
Pain that is felt at a location away from its source
-
Past History
- General state of health
- Childhood diseases
- Adult diseases
- Psychiatric illness
- Accidents or injuries
- Surgeries or hospitalizations
-
Current Health Status
- Current medications
- Allergies
- Tobacco
- Alcohol, drugs and substances
- Diet
- Screening tests
- Immunizations
- Sleep patterns
- Exercise/leisure
- Environmental hazards
- Use of safety measures
- Family history
- Home situation and significant others
- Daily life
- Important experiences
- Religious beliefs
- Patient's outlook
-
CAGE Questionairre
- Cut down on your drinking?
- Annoyed by criticism of your drinking?
- Guilty feelings about drinking?
- Eye-opener in the morning?
-
Review of Systems
List of questions categorized by body system
- General- weight gain, fatigue
- Skin- lumps, sores, dryness
- Head, eyes, ears, nose and throat (HEENT)
- Respiratory- wheezing, coughing, pneumonia
- Cardiac- chest pain, palpitations, SOB
- Gastrointestinal- bowel movements, vomitting
- Urinary- pain, blood, color, excessive
- Male genitalia- sores, masses
- Female genitalia- periods, bleeding, pain, pregnancies
- Peripheral vascular- pain
- Musculoskeletal- pain
- Neurological- weakness, numbness
- Hematologic- anemia, blood transfusions
- Endocrine- thyroid, sweating
- Psychiatric- nervous, stress
-
Tinnitus
Sensation of ringing in the ears
-
Hemoptysis
Coughing up blood
-
Dyspnea
Difficulty breathing
-
Orthopnea
Difficulty breathing while supine
-
Paroxysmal Nocturnal Dyspnea
Sudden onset of SOB at night
-
Hematemesis
Vomitting blood
-
Polyuria
Excessive urination
-
Nocturia
Excessive urination at night
-
-
Dysmenorrhea
Difficult or painful menstruation
-
Intermittent Claudication
Intermittent calf pain while walking that subsides with rest
-
Special Challenges
- Silence
- Overly Talkative
- Multiple Symptoms
- Anxious
- Needing Reassurance
- Anger/Hostility
- Intoxication
- Crying
- Depression
- Sexually Attractive Patients
- Confusing Behaviors/Histories
- Limited Intelligence
- Language Barriers
- Hearing Problems
- Blindness
- Talking with Family or Friends
-
Depression
A mood disorder characterized by hopelessness and malaise
-
Dementia
A deterioration of mental status that is usually associated with structural neurologic disease
-
Delirium
An acute alteration in mental functioning that is often reversible
|
|
